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Ethics Committees in Canadian Hospitals: Report of the 1989 Survey
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Article original
Original Article
A survey.of English-language hospitals with more than 300 beds in Canada was conducted in 1989 to assess institutional ethics committees. A dramatic increase wasfound in the growth ofsuch committees, compared with a similar survey taken in 1984. The growth and the activities of institutional ethics committees are discussed, noting the need for more attention for research on their eflectiveness.
Ethics Committees in Canadian Hospitals: Report of the 1989 Survey by Janet L. Storch, Glenn G. Griener, Deborah A. Marshall and Beverly A. Olineck
I
t is evident from the current literature and from presentations at conferences and seminars that health care practitioners,bioethicists, hospital administrators and hospital boards continue to be interested in institutional ethics committees. Publications can be found in a wide variety of journals ranging from the Journal of the American Medical Association and Annals of Internal Medicine to the Quality Review Bulletin and Social Work in Health Care. The articles focus on the historical development of ethics committees,’*2the nature, purpose and responsibility of ethics Committees 3-7 organization and membership8-12and survey reports of the distribution and function of ethics The Canadian Council on Health Facilities Accreditation and the Canadian Hospital Association have also exhibited a growing interest in institutional ethics committees. For example, in the 1972 Accreditation Guide, reference was made in the Reamble to the need to evaluate health care activities with regard to patients’ rights. These considerations were reflected in certain general principles set for health care facilities.By 1986, the guidelines stipulated,in Section 6.1.1 under Biomedical Ethics, that “the facility shall address the need for policies on the following biomedical ethical subjects: informed consent; patient choice of treatment; ‘refusalof treatment, accessibility of treatment; withholding of treatment; restraints, abortion and other issues related to biomedical ethics.” Sections 6.2 and 6.3 further specified that “this process may be facilitated by the creation of a multidisciplinary ethics committee,“whose membership” should include representatives from at least: the governing body; the administration; the medical staff; and other professional staff, as appr~priate”.’~ In the same year, the Canadian Hospital Association issued a policy statement recommending institutional ethics committees.’ Despite the growing interest in institutional ethics committees, there has been no recently published study of their numbers and types in Canada, or their effectiveness. The latest comprehensive survey was conducted by Avard, Griener and Langstaff16in 1984. These researchers surveyed all 215 hospitals in Canada with at least 300 beds. Of the 196 questionnaires that were returned, 36 hospitals (26 English-language)reported having an ethics committee.
committee^.^^-'^
*
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The major activities of hospital ethics committees were to review ethical issues in order to recommend policies and procedures to the board (78%), to counsel physicians (72%)and to educate staff regarding ethical matters (72%).There was a great deal of variation in size, compositionand procedural mechanisms. Physicians (92%),nurses (81%),clergy and ethicists (86%)and administrators(75%) were the most usual professionalson the committees. Most of them met regularly and on demand (69%);92% kept minutes. Although the 1984 study provided useful descriptive data about the existence, function and composition of ethics committeesin Canada,the researchers were unable to determine their effectiveness. Given the apparent promotion of these committees,there is a pressing need to examine more closely their functioning and role, and their effectivenessin particular. Thus, a decision was made by researchers involved with the Joint-FacultiesBioethics Project at the University of Alberta to conduct a pilot study to assess the effectivenessof ethics committeesof English-languagehospitals. The initial phase of the study involved a repeat of the 1984 survey of hospitals with 300 or more beds to provide updated information on the numbers, types and functions of ethics committee^.^ This was the first step toward selecting institutional ethics committees for a further detailed study of effectiveness.
Study methodology Letters were sent in 1989 to the chief executive officers (CEOs) of all 142 English-languagehospitals in Canada with more than 300 beds asking them to complete a Hospital Ethics Committee Survey. To ensure that our data could be compared with the previous data, we used the same instrument as Avard and colleagues.16This questionnairewas composed of closed and open-endedquestions that focused on the structure, proceedings and purpose of hospital ethics committees. A hospital ethics committee was defmed as “any committee that is recognized as being primarily involved in ethical issues regarding patient care”.
Results A total of 123 questionnaireswere returned from the 142 eligible hospitals for an overall response rate of 86.6% (usable response rate 120 or 84.5%). Seventy-twoof the responses indicated the hospital had an ethics committee. However, two were reclassified to the 48 that responded they did not have an ethics committee; these committeeswere actually research ethics review committeesthat did not deal with direct patient care issues. In the 70 hospitals (58.3%)deemed to have an ethics committee in accordance with the previous definition, there was a range of committee titles: Ethics and Biomedical Assessment Committee, Ethics Interest Group, Ethics Consultation Committee,
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Figure 1: Formation of Ethics Committees in Canadian Hospitals -., , 24 27 -_
20 18 16 14 12 10 8 6 4 2
0 Prior
1981 1980
1983 1982
1985 1984
1986
1987 1989 1988 Blank
Year Committee Established
Medico-MoralCommittee,Patient Rights and Ethics Committee, and Bioethics Committee. There was a substantial growth in ethics committeesin English-languagehospitals over the five years; 70 in 1989compared with 26 in 1984. (If French-language hospitals had been included in the 1989 survey, the number of ethics committeesidentified may have been greater.) Figure 1 shows the frequency distribution of the date of establishmentof these ethics committees. There was a dramatic increase in the number of committeesin 1988,when 30% were formed (see Figure 1). This phenomenon can be reasonabl linked to the Canadian Hospital Association’s policy statementYs and the change in the Guide to Accreditation of Health Cure Facilitie~’~ in 1986,which suggested that health care facilities might establish a multidisciplinarycommittee to address the need for policies on biomedical ethical subjects. It may be that hospitals took this advice to be an accreditation standard. Given that institutions are commonly accredited every two years, 1988 may have beewthe first year that the 1986 guidelines were applicable to many institutions.
Committee composition Respondentswere asked to rank the top three people most instrumental in establishing the committee. Physicians and administraton were ranked 25% of the time, nurses (13%),board members (11%)and clergy (8%). The size of these committeesranged from five to twenty-five members with a mean of thirteen (57% of the committeesranged between ten and thirteen members). Nurses, physicians and clergy were almost invariablyrepresented on the committees (see Table 1). Social workers (78%)and board members (59%) were the only others listed as members by more than 50% of the
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respondents. On any given committee, the number of physician and nurse members ranged from one to seven. Six hospitals had six or more physicians on their committee and two had more than six nurses (see Table 2).
Scope of responsibility
Table 1: Representationon Ethics Committees Physicians Nurses Clergy Administrators
1984 92% 81 86 75
1989 97% 99 97 94
Table 2: Numbers Representedon Ethics Committees Physicians Nurses Administrators Clergy
1 12 25 46 57
No. of persons on committee 2-3 4-5 27 23 39 3 1 17 10
0
Twenty-nine(41%) of the respondents indicated that they had one bioethicist on the committee and two hospitals had two. (The specific category of “bioethicist” was added to the questionnaire for the 1989 study.)
Proceedings Most (64%) of the respondents indicated that ethics committee members were selected by appointmentonly. In seven cases (lo%), membership is on a volunteer basis only. Most of the ethics committees met either regularly, or regularly and on demand (87%). Only in nine did the committees meet solely on demand. Since August 1, 1988,the mean number of committee meetings reported by all respondents in total was seven, although a few had met on more than 10 occasions (16%). Formal records of meetings are kept by most committees (94%). Table 3 shows the types of people from whom referrals of cases to ethics committees will be accepted. Although one cannot determine how often individuals in these various groups might refer items to the committee, a wide range of people Seem to have the freedom to do so.
I Table 3: Referrals to Ethics Committees
(Question: Who can refer an issue to your committee?) Group No. of Committees % of Committees Attending physician 62 88.6 Patientlfamily 52 74.3 Nurse 62 87.1 Other health care professional 65 92.9 Administrator 60 85.7 Other 27 38.6
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Eighty-sevenpercent of respondents indicated that their ethics committee served primarily in an advisory or consultative capacity (comparedwith 83% in 1984). Only one hospital in 1989reported the committee’sprimary role was considered to be one of decision-makingcompared with three hospitals in 1989. In some institutions the committee’sprimary role was neither advisory nor decision-making;instead it was policy review and formulation, education and the identification of significant trends in bioethics. Respondentswere asked to choose which activities their committees were responsible for from a given list (see Table 4). The two most common responses were: (1) to review ethics1 issues in patient care in order to recommend policies and procedures to the hospital board (85%)and (2) to provide for continuing educational needs of hospital personnel relating to ethical matters (77%). Many respondents indicated that counselling and support activities for physicians (60%)and other health care professionals (63%) were also important. Only nine committees (13%)were involved in a decision-makingrole about continuing life support, although in eight it was not the primary role. Other roles identified by the respondents included: “to educate the hospital and city community”,“to provide staff and board with current information about ethical concerns”, “to review all restricting practices”, “to encourageresearch in bioethics” and “to review, as requested,treatment decisions on behalf of incompetentand terminally ill patients”.
Table 4: Activities of Hospital Ethics Committees (hospitals: n = 70) (Question: Does your hospital ethics committee serve in the following capacities? Choose all that apply; feel free to add others) Activity Yes Confirm medical prognosis 1 1 Review ethical issues in order to @commend 60 85 policies and procedures to the hospital board Counsel and support patients and families 31 44 Counsel and support health professionals 44 63 Counsel and support physicians 42 60 Meet educational needs of hospital personnel 54 77 relating to ethical matters Make decisions about continuing life support 9 13
Asked whether hospital ethics committees should be involved in addressing specific issues, 114 of the 120 (95%)responding hospitals, indicated that they should provide staff with current information on ethical problems. Other issues supported as desirable concerns included life and death issues (87%), termina-
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Figure 2: Do You Have Any Other Comments about the Functions and Effect of a Hospital Ethics Committee? Responses from hospitals with no ethics committee
Responses from hospitals with an ethics committee
At present, a centralized committee would be redundant. Ethical issues can mostly be resolved by an ad hoc multidisciplinary team.
Hospitals can become busy places, with an emphasis on serving. The ethics committee can offer the opportunity to reflect on that serving. Reflection, however, can threaten our identity and role, but it has the capacity to bring integrity to our functioning as caregivers. An ethics committee is seen variously as a threat, a non-entity, or a valuable resource. . . The ethics committee should get into patient care issues immediately, rather than debate ethical issues constantly and exclusively. It needs to be well known and respected in the hospital to have an impact. This does not happen quickly or on its own, but needs aplan to promote its purpose. I believe a hospital ethics committee can serve as a positive role in supporting hospital staff and patients. Our committee has had very positive effects; physicians and nurses feel comfortable enough to request meetings to discuss concerns. We have even had the patient concerned and the relatives present with very good results.
My question would be how do you determine if you need an ethics committee and how do you establish one? To be at all effective it must be endorsed and supported by the medical staff. Can this function be covered by an existing committee? We are concerned about the amount of time and work, and the number of committees already in existence. I believe that a hospital ethics committee cannot be formed or function without the active support of the medical staff. They work well when there is mutual respect among members, a willingness to learn and an organized approach to issues raised at committee meetings. Should function at a policy level and not get involved in individual cases.
tion of treatment (83%)and clinical care policies and practices (83%).One issue in which most respondents felt that hospital ethics committees should not be involved was the evaluation of patient competency/incompetency(60%)(see Table 5).
Table 5: Issues in Which Ethics Committees Should be Involved (Question: Are these issues in which you believe hospital ethics committees should be involved?) Issue All Respondents Answering (n = 120) Yes No Noopinion Blank Evaluation of patient competen40 72 4 4 cyhncompetency 1 1 Termination of treatment 99 19 Cost benefit (resource allocation) 75 28 13 4 Life and death issues 104 9 4 3 Provide counsel to and support for 77 33 5 5 patientsflamily Provide counsel to and support for 70 17 4 29 staff Provide staff with current informa- 114 2 2 2 tion in the field of ethical problems Clinical care policies and practices 99 13 4 4 Other 20 0 0 100
In evaluating the effect of hospital ethics committeeson specific activities, only in one case-that of providmg a form of
legal protection for hospital and medical staff-did a minority of respondents reply that the effect was beneficial. The remaining activities were identified as being beneficial by most respondents. These included shaping hospital policies with regard to life support, educating staff about issues involved in life support, providing an opportunity for health professionals to discuss issues, increasing the ability of individuals and patients to influence the decision-makingprocess, improving the quality of care for patients, providing counsel and support for the hospital medical staff and providing a forum for answering tough ethical questions. The uniformly positive response regarding the beneficial effects of such committees may also be a function of biased reporting. Because the CEO of each institution completed the questionnaire or designated someo'ne, a variety of people completed the questionnaires,including seven CEOs, twenty-two chairmen of ethics committees, six senior medical staff, thntythree vice-presidentsor directors and four people who indicated they were bioethicists or members of ethics committees.Thus, in addition to a bias created by selection, there may be problems of reliability of data because perceptions of the role of the ethics committee may vary dependingon the degree of involvement with the committee. (One hospital returned two surveys at different times, filled out by people in two different positions. There were differencesin the responses to the questions regarding the role and establishmentof ethics committees.) Additional comments on the function and effect of hospital ethics committees were invited (see Figure 2).
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Summary and Comparison of Findings The 1989 survey showed that ethics committeeswere established in 70 out of 120 (58.3%) of English-languagehospitals in Canada with over 300 beds. This was a dramatic increase since 1984 when only 18%of Canadian hospitals (includingFrenchlanguage institutions) had such committees.Results of the survey revealed that much of the increase occurred in 1988,when 30% of these committeeswere formally established. As in the 1984 study, physicians and administratorswere ranked among the top three people instrumentalin establishing the committee.Our study is also similar to the 1984 study in terms of committee membership, except for the increased presence of nurses-98.6% in 1989 versus 81% in 1984-which included French- and English-languagehospitals. However, physicians (97.1%), administrators (94.3%) and clergy (97.1%) were still the predominant members. Most ethics committees met regularly, or both regularly and on demand (87%),kept formal records (94%) and accepted referrals from many groups. The advisory and consultative role of the ethics committee is still the most common, with few (only one in 1989)that consider themselves as decisionmakers. The data are again similar to the 1984 survey regarding the more specific activities of hospital ethics committees.Policy recommendation (86%),staff education (77%) and physicianhealth professional counselling (60%/63%)were the most frequently indicated activities. In general, the status of ethics committeesin Canadian hospitals in terms of structure, proceedingsand responsibility is similar to that in 1984. The most significantchange was the vast increase in the actual number of committees. The survey results show that the trend to establish hospital ethics committees, which began in the early 1980s,acceleratedduring the second half of the decade. The newer ethics committees seem to have followed the model set by the old; this has occurred although the effectiveness of the older committees has never been evaluated. Hospital administrators should be acutely aware of the need for careful scrutiny. Given the size of these committees and their broad mandates in consultation,education and policy formation,there could be the potential for a considerable investmentof staff members’ time in ethics committee work. Is this time well spent? The need for evaluation is also sharpenedbecause of the creation of the role of clinical bioethicist. Some hospitals are attempting to meet the need for ethics consultation and education by hiring peo le trained in bioethics, typically philosophers,physiciansI$ or other health care professionals. This developmentraises the question of the appropriate structure for addressing the institution’s ethical concerns. Do ethics committees serve a useful purpose? Another reason for evaluation is that established hospital ethics committeesmay be broadening their mandates. In particular,
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committees may become involved in issues of resource allocation?’ Although committeeshave attempted to resist the intrusion of cost considerationsinto consultations about a particular patient’s care, ethics committees may be asked to review decisions to close beds or to offer expensive new treatments. Do ethics committees have a role in decisions of resource allocation? Other questions relate to the advisory nature of the ethics committees.Are physicians free to take or refuse such advice, or does the advice impose a decision? A questionnairesent by mail has serious limitations in its ability to determine the accuracy and meaning of the data, making the assessment of the actual and potential functions of these committeesdifficult. To attempt to answer the many questions regarding the function and effectivenessof ethics committees, the second phase of the study is in progress. This stage involves site visits to selected hospitals to interview committee members, users and non-users of the institutional ethics committee and administrators.The findings of the pilot study on effectivenessof such committees will be reported in a subsequentarticle.
References and notes 1. Rosner, F. 1985. Hospital medical ethics committees: a review of their development.Journal of the American Medical Association 253( 18), 2693-2697. 2. Sweeney, R.H. 1987. Past, present, and future of hospital ethics committees.Delaware Medical Journal 59(3), 181-184. 3. Callahan, S . 1988. Ethics by committee?Health Progress 69(8), 76-78. 4. Cranford, R.E. and Roberts, J.C. 1986. Ethics committees: one of us is as smart as all of us. Michigan Hospitals 22(12), 14-16,31-34. 5. Cross, A.W. 1986. Pediatric ethics committees: learning from our experience. Journal of Pedianics 108(2), 242-243. 6. Robertson, J.D. 1984. Ethics committees in hospitals: alternative structures and responsibilities. Quality Review Bulletin 10,6-10. 7. Thomasma, D.C. 1985. Hospital ethics committees and hospital policy. Quality Review Bulletin 11(6), 204-209. 8. Fost, N. and Cranford,R.E. 1985. Hospital ethics committees: administrative aspects. Journal ofthe American Medical Association 253( 18), 2687-2692. 9. Linfors, E.W. 1988. How should hospital ethics committees function?Who should be included? North Carolina Medical Journal 49(3), 157-162. 10. Cranford, R.E. and Van Allen, E.J. 1985. The implications
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and applications of institutionalethics committees. American College of Surgeons Bulletin 70(6), 19-24. 11. Furlong, R.M. 1986.The social worker’s role on the institutional ethics committee. Social Work in Health Care 11(4), 93-100. 12. Fleetwood, J.E., Arnold, R.M. and Baron, R.J. 1989. Giving answers or raising questions? The problematic role of institutional ethics committees.Journal of Medical Ethics 15,137-142. 13. Van Allen, E.A. and Miles, S.H. 1987. Ethics committees in Minnesota hospitals. Minnesota Medicine 70(2), 77-80. 14. Green, W. 1989. The Philadelphia story. Hastings Centre Report 19(5), 26. 15. Brown, B.A., Miles, S.H. and Avoskar, M.A. 1987. The prevalence and design of ethics committees in nursing homes. Journal of the American Geriatric Society 35(1l), 1028-1033. 16. Avard, D., Griener, G. and Langstaff,J. 1985. Hospital ethics committees: survey reveals characteristics. Dimensions 62(2), 24-26. 17. Canadian Council on Hospital Accreditation. 1986. Guide to Accreditation of Canadian Health Care Facilities, CCHA, Ottawa. 18. Canadian Hospital Association. 1986.Institutional Ethics Committees: Recommendationsfor Action, CHA, Ottawa. 19. La Puma, J., Stocking,C.B., Silverstein,M.D. et al. 1988. An ethics consultation service in a teaching hospital. Journal of the American Medical Association 260(6), 808-811. 20. Cohen, C.B. 1990. The adolescence of ethics committees. Hastings Center Report 20(2), 19. This research was supported by a grant from National Health Research Development Program (NHRDP), Ottawa.
Appendix Considerationsin Establishingan Ethics Committee Some authors have suggested approaches to establishing ethics committees.They are summarized below, and include selected references.
1. Three or four interested staff members (nurses, physicians or other health professionals) form a committee and seek other interested members who are good listeners, or a hospital board selects some key staff members to “lead” in the formation of a committee. 2. Engage in committee self-education (e.g., reading, discussion, outside speakers) to become better acquainted with ethics in general, and the function of ethics committees in particular. 3. Determine the mission of the committee and gradually formulate guidelines, while remaining oriented to the process of developing the committee. 4. Work to enhance multidisciplinaryinvolvement, allowing members to get to know one another and to appreciate each other’s perspectives. 5. Proceed slowly, expecting some resistance. The committee should seek to earn acceptance. 6. Determine the authority your committee will have, and develop a framework for education and consultation. Cranford, R.E. and Roberts, J.C. 1986. Ethics Committees: none of us is as smart as all of us. Michigan Hospitals 22(12), 14-16,31-34. Linfors, E.W. ( 4 ) . 1988. Hospital ethics committees.North Carolina Medical Journal 49(3), 157-159. Niemira, Denise A. 1988. Grassroots grappling: ethics committees in rural hospitals. Annals ofhternal Medicine Dec. 15,981-983. Rues, L.A. 1987. Starting an institutionalethics committee: one physician’s experience,Healthcare Executive 2(4): 34-38. Weeks, L.C. 1987. Ethics committees.Journal of Nursing Administration 17(10),31-32. Janet L. Storch, RN,MHSA, PhD, is Professor and Dean, Faculty of Nursing, UniversiG of Calgary. Glenn G . Griener, BS, MA, PhD, is Assistant Professor, Medicine. Philosophy and Nursing, University of Alberta. Deborah A. Marshall, BSc, MHSA, is Administrative Fellow, University Hospital, Vancouver. Beverly A. Olineck, BComm, MHSA, is Administrative Fellow, St. Paul’s Hospital (GreyNuns), Saskatoon.
El
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Article original
Original Article
A survey.of English-language hospitals with more than 300 beds in Canada was conducted in 1989 to assess institutional ethics committees. A dramatic increase wasfound in the growth ofsuch committees, compared with a similar survey taken in 1984. The growth and the activities of institutional ethics committees are discussed, noting the need for more attention for research on their eflectiveness.
Ethics Committees in Canadian Hospitals: Report of the 1989 Survey by Janet L. Storch, Glenn G. Griener, Deborah A. Marshall and Beverly A. Olineck
I
t is evident from the current literature and from presentations at conferences and seminars that health care practitioners,bioethicists, hospital administrators and hospital boards continue to be interested in institutional ethics committees. Publications can be found in a wide variety of journals ranging from the Journal of the American Medical Association and Annals of Internal Medicine to the Quality Review Bulletin and Social Work in Health Care. The articles focus on the historical development of ethics committees,’*2the nature, purpose and responsibility of ethics Committees 3-7 organization and membership8-12and survey reports of the distribution and function of ethics The Canadian Council on Health Facilities Accreditation and the Canadian Hospital Association have also exhibited a growing interest in institutional ethics committees. For example, in the 1972 Accreditation Guide, reference was made in the Reamble to the need to evaluate health care activities with regard to patients’ rights. These considerations were reflected in certain general principles set for health care facilities.By 1986, the guidelines stipulated,in Section 6.1.1 under Biomedical Ethics, that “the facility shall address the need for policies on the following biomedical ethical subjects: informed consent; patient choice of treatment; ‘refusalof treatment, accessibility of treatment; withholding of treatment; restraints, abortion and other issues related to biomedical ethics.” Sections 6.2 and 6.3 further specified that “this process may be facilitated by the creation of a multidisciplinary ethics committee,“whose membership” should include representatives from at least: the governing body; the administration; the medical staff; and other professional staff, as appr~priate”.’~ In the same year, the Canadian Hospital Association issued a policy statement recommending institutional ethics committees.’ Despite the growing interest in institutional ethics committees, there has been no recently published study of their numbers and types in Canada, or their effectiveness. The latest comprehensive survey was conducted by Avard, Griener and Langstaff16in 1984. These researchers surveyed all 215 hospitals in Canada with at least 300 beds. Of the 196 questionnaires that were returned, 36 hospitals (26 English-language)reported having an ethics committee.
committee^.^^-'^
*
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The major activities of hospital ethics committees were to review ethical issues in order to recommend policies and procedures to the board (78%), to counsel physicians (72%)and to educate staff regarding ethical matters (72%).There was a great deal of variation in size, compositionand procedural mechanisms. Physicians (92%),nurses (81%),clergy and ethicists (86%)and administrators(75%) were the most usual professionalson the committees. Most of them met regularly and on demand (69%);92% kept minutes. Although the 1984 study provided useful descriptive data about the existence, function and composition of ethics committeesin Canada,the researchers were unable to determine their effectiveness. Given the apparent promotion of these committees,there is a pressing need to examine more closely their functioning and role, and their effectivenessin particular. Thus, a decision was made by researchers involved with the Joint-FacultiesBioethics Project at the University of Alberta to conduct a pilot study to assess the effectivenessof ethics committeesof English-languagehospitals. The initial phase of the study involved a repeat of the 1984 survey of hospitals with 300 or more beds to provide updated information on the numbers, types and functions of ethics committee^.^ This was the first step toward selecting institutional ethics committees for a further detailed study of effectiveness.
Study methodology Letters were sent in 1989 to the chief executive officers (CEOs) of all 142 English-languagehospitals in Canada with more than 300 beds asking them to complete a Hospital Ethics Committee Survey. To ensure that our data could be compared with the previous data, we used the same instrument as Avard and colleagues.16This questionnairewas composed of closed and open-endedquestions that focused on the structure, proceedings and purpose of hospital ethics committees. A hospital ethics committee was defmed as “any committee that is recognized as being primarily involved in ethical issues regarding patient care”.
Results A total of 123 questionnaireswere returned from the 142 eligible hospitals for an overall response rate of 86.6% (usable response rate 120 or 84.5%). Seventy-twoof the responses indicated the hospital had an ethics committee. However, two were reclassified to the 48 that responded they did not have an ethics committee; these committeeswere actually research ethics review committeesthat did not deal with direct patient care issues. In the 70 hospitals (58.3%)deemed to have an ethics committee in accordance with the previous definition, there was a range of committee titles: Ethics and Biomedical Assessment Committee, Ethics Interest Group, Ethics Consultation Committee,
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Figure 1: Formation of Ethics Committees in Canadian Hospitals -., , 24 27 -_
20 18 16 14 12 10 8 6 4 2
0 Prior
1981 1980
1983 1982
1985 1984
1986
1987 1989 1988 Blank
Year Committee Established
Medico-MoralCommittee,Patient Rights and Ethics Committee, and Bioethics Committee. There was a substantial growth in ethics committeesin English-languagehospitals over the five years; 70 in 1989compared with 26 in 1984. (If French-language hospitals had been included in the 1989 survey, the number of ethics committeesidentified may have been greater.) Figure 1 shows the frequency distribution of the date of establishmentof these ethics committees. There was a dramatic increase in the number of committeesin 1988,when 30% were formed (see Figure 1). This phenomenon can be reasonabl linked to the Canadian Hospital Association’s policy statementYs and the change in the Guide to Accreditation of Health Cure Facilitie~’~ in 1986,which suggested that health care facilities might establish a multidisciplinarycommittee to address the need for policies on biomedical ethical subjects. It may be that hospitals took this advice to be an accreditation standard. Given that institutions are commonly accredited every two years, 1988 may have beewthe first year that the 1986 guidelines were applicable to many institutions.
Committee composition Respondentswere asked to rank the top three people most instrumental in establishing the committee. Physicians and administraton were ranked 25% of the time, nurses (13%),board members (11%)and clergy (8%). The size of these committeesranged from five to twenty-five members with a mean of thirteen (57% of the committeesranged between ten and thirteen members). Nurses, physicians and clergy were almost invariablyrepresented on the committees (see Table 1). Social workers (78%)and board members (59%) were the only others listed as members by more than 50% of the
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respondents. On any given committee, the number of physician and nurse members ranged from one to seven. Six hospitals had six or more physicians on their committee and two had more than six nurses (see Table 2).
Scope of responsibility
Table 1: Representationon Ethics Committees Physicians Nurses Clergy Administrators
1984 92% 81 86 75
1989 97% 99 97 94
Table 2: Numbers Representedon Ethics Committees Physicians Nurses Administrators Clergy
1 12 25 46 57
No. of persons on committee 2-3 4-5 27 23 39 3 1 17 10
0
Twenty-nine(41%) of the respondents indicated that they had one bioethicist on the committee and two hospitals had two. (The specific category of “bioethicist” was added to the questionnaire for the 1989 study.)
Proceedings Most (64%) of the respondents indicated that ethics committee members were selected by appointmentonly. In seven cases (lo%), membership is on a volunteer basis only. Most of the ethics committees met either regularly, or regularly and on demand (87%). Only in nine did the committees meet solely on demand. Since August 1, 1988,the mean number of committee meetings reported by all respondents in total was seven, although a few had met on more than 10 occasions (16%). Formal records of meetings are kept by most committees (94%). Table 3 shows the types of people from whom referrals of cases to ethics committees will be accepted. Although one cannot determine how often individuals in these various groups might refer items to the committee, a wide range of people Seem to have the freedom to do so.
I Table 3: Referrals to Ethics Committees
(Question: Who can refer an issue to your committee?) Group No. of Committees % of Committees Attending physician 62 88.6 Patientlfamily 52 74.3 Nurse 62 87.1 Other health care professional 65 92.9 Administrator 60 85.7 Other 27 38.6
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Eighty-sevenpercent of respondents indicated that their ethics committee served primarily in an advisory or consultative capacity (comparedwith 83% in 1984). Only one hospital in 1989reported the committee’sprimary role was considered to be one of decision-makingcompared with three hospitals in 1989. In some institutions the committee’sprimary role was neither advisory nor decision-making;instead it was policy review and formulation, education and the identification of significant trends in bioethics. Respondentswere asked to choose which activities their committees were responsible for from a given list (see Table 4). The two most common responses were: (1) to review ethics1 issues in patient care in order to recommend policies and procedures to the hospital board (85%)and (2) to provide for continuing educational needs of hospital personnel relating to ethical matters (77%). Many respondents indicated that counselling and support activities for physicians (60%)and other health care professionals (63%) were also important. Only nine committees (13%)were involved in a decision-makingrole about continuing life support, although in eight it was not the primary role. Other roles identified by the respondents included: “to educate the hospital and city community”,“to provide staff and board with current information about ethical concerns”, “to review all restricting practices”, “to encourageresearch in bioethics” and “to review, as requested,treatment decisions on behalf of incompetentand terminally ill patients”.
Table 4: Activities of Hospital Ethics Committees (hospitals: n = 70) (Question: Does your hospital ethics committee serve in the following capacities? Choose all that apply; feel free to add others) Activity Yes Confirm medical prognosis 1 1 Review ethical issues in order to @commend 60 85 policies and procedures to the hospital board Counsel and support patients and families 31 44 Counsel and support health professionals 44 63 Counsel and support physicians 42 60 Meet educational needs of hospital personnel 54 77 relating to ethical matters Make decisions about continuing life support 9 13
Asked whether hospital ethics committees should be involved in addressing specific issues, 114 of the 120 (95%)responding hospitals, indicated that they should provide staff with current information on ethical problems. Other issues supported as desirable concerns included life and death issues (87%), termina-
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Figure 2: Do You Have Any Other Comments about the Functions and Effect of a Hospital Ethics Committee? Responses from hospitals with no ethics committee
Responses from hospitals with an ethics committee
At present, a centralized committee would be redundant. Ethical issues can mostly be resolved by an ad hoc multidisciplinary team.
Hospitals can become busy places, with an emphasis on serving. The ethics committee can offer the opportunity to reflect on that serving. Reflection, however, can threaten our identity and role, but it has the capacity to bring integrity to our functioning as caregivers. An ethics committee is seen variously as a threat, a non-entity, or a valuable resource. . . The ethics committee should get into patient care issues immediately, rather than debate ethical issues constantly and exclusively. It needs to be well known and respected in the hospital to have an impact. This does not happen quickly or on its own, but needs aplan to promote its purpose. I believe a hospital ethics committee can serve as a positive role in supporting hospital staff and patients. Our committee has had very positive effects; physicians and nurses feel comfortable enough to request meetings to discuss concerns. We have even had the patient concerned and the relatives present with very good results.
My question would be how do you determine if you need an ethics committee and how do you establish one? To be at all effective it must be endorsed and supported by the medical staff. Can this function be covered by an existing committee? We are concerned about the amount of time and work, and the number of committees already in existence. I believe that a hospital ethics committee cannot be formed or function without the active support of the medical staff. They work well when there is mutual respect among members, a willingness to learn and an organized approach to issues raised at committee meetings. Should function at a policy level and not get involved in individual cases.
tion of treatment (83%)and clinical care policies and practices (83%).One issue in which most respondents felt that hospital ethics committees should not be involved was the evaluation of patient competency/incompetency(60%)(see Table 5).
Table 5: Issues in Which Ethics Committees Should be Involved (Question: Are these issues in which you believe hospital ethics committees should be involved?) Issue All Respondents Answering (n = 120) Yes No Noopinion Blank Evaluation of patient competen40 72 4 4 cyhncompetency 1 1 Termination of treatment 99 19 Cost benefit (resource allocation) 75 28 13 4 Life and death issues 104 9 4 3 Provide counsel to and support for 77 33 5 5 patientsflamily Provide counsel to and support for 70 17 4 29 staff Provide staff with current informa- 114 2 2 2 tion in the field of ethical problems Clinical care policies and practices 99 13 4 4 Other 20 0 0 100
In evaluating the effect of hospital ethics committeeson specific activities, only in one case-that of providmg a form of
legal protection for hospital and medical staff-did a minority of respondents reply that the effect was beneficial. The remaining activities were identified as being beneficial by most respondents. These included shaping hospital policies with regard to life support, educating staff about issues involved in life support, providing an opportunity for health professionals to discuss issues, increasing the ability of individuals and patients to influence the decision-makingprocess, improving the quality of care for patients, providing counsel and support for the hospital medical staff and providing a forum for answering tough ethical questions. The uniformly positive response regarding the beneficial effects of such committees may also be a function of biased reporting. Because the CEO of each institution completed the questionnaire or designated someo'ne, a variety of people completed the questionnaires,including seven CEOs, twenty-two chairmen of ethics committees, six senior medical staff, thntythree vice-presidentsor directors and four people who indicated they were bioethicists or members of ethics committees.Thus, in addition to a bias created by selection, there may be problems of reliability of data because perceptions of the role of the ethics committee may vary dependingon the degree of involvement with the committee. (One hospital returned two surveys at different times, filled out by people in two different positions. There were differencesin the responses to the questions regarding the role and establishmentof ethics committees.) Additional comments on the function and effect of hospital ethics committees were invited (see Figure 2).
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Summary and Comparison of Findings The 1989 survey showed that ethics committeeswere established in 70 out of 120 (58.3%) of English-languagehospitals in Canada with over 300 beds. This was a dramatic increase since 1984 when only 18%of Canadian hospitals (includingFrenchlanguage institutions) had such committees.Results of the survey revealed that much of the increase occurred in 1988,when 30% of these committeeswere formally established. As in the 1984 study, physicians and administratorswere ranked among the top three people instrumentalin establishing the committee.Our study is also similar to the 1984 study in terms of committee membership, except for the increased presence of nurses-98.6% in 1989 versus 81% in 1984-which included French- and English-languagehospitals. However, physicians (97.1%), administrators (94.3%) and clergy (97.1%) were still the predominant members. Most ethics committees met regularly, or both regularly and on demand (87%),kept formal records (94%) and accepted referrals from many groups. The advisory and consultative role of the ethics committee is still the most common, with few (only one in 1989)that consider themselves as decisionmakers. The data are again similar to the 1984 survey regarding the more specific activities of hospital ethics committees.Policy recommendation (86%),staff education (77%) and physicianhealth professional counselling (60%/63%)were the most frequently indicated activities. In general, the status of ethics committeesin Canadian hospitals in terms of structure, proceedingsand responsibility is similar to that in 1984. The most significantchange was the vast increase in the actual number of committees. The survey results show that the trend to establish hospital ethics committees, which began in the early 1980s,acceleratedduring the second half of the decade. The newer ethics committees seem to have followed the model set by the old; this has occurred although the effectiveness of the older committees has never been evaluated. Hospital administrators should be acutely aware of the need for careful scrutiny. Given the size of these committees and their broad mandates in consultation,education and policy formation,there could be the potential for a considerable investmentof staff members’ time in ethics committee work. Is this time well spent? The need for evaluation is also sharpenedbecause of the creation of the role of clinical bioethicist. Some hospitals are attempting to meet the need for ethics consultation and education by hiring peo le trained in bioethics, typically philosophers,physiciansI$ or other health care professionals. This developmentraises the question of the appropriate structure for addressing the institution’s ethical concerns. Do ethics committees serve a useful purpose? Another reason for evaluation is that established hospital ethics committeesmay be broadening their mandates. In particular,
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committees may become involved in issues of resource allocation?’ Although committeeshave attempted to resist the intrusion of cost considerationsinto consultations about a particular patient’s care, ethics committees may be asked to review decisions to close beds or to offer expensive new treatments. Do ethics committees have a role in decisions of resource allocation? Other questions relate to the advisory nature of the ethics committees.Are physicians free to take or refuse such advice, or does the advice impose a decision? A questionnairesent by mail has serious limitations in its ability to determine the accuracy and meaning of the data, making the assessment of the actual and potential functions of these committeesdifficult. To attempt to answer the many questions regarding the function and effectivenessof ethics committees, the second phase of the study is in progress. This stage involves site visits to selected hospitals to interview committee members, users and non-users of the institutional ethics committee and administrators.The findings of the pilot study on effectivenessof such committees will be reported in a subsequentarticle.
References and notes 1. Rosner, F. 1985. Hospital medical ethics committees: a review of their development.Journal of the American Medical Association 253( 18), 2693-2697. 2. Sweeney, R.H. 1987. Past, present, and future of hospital ethics committees.Delaware Medical Journal 59(3), 181-184. 3. Callahan, S . 1988. Ethics by committee?Health Progress 69(8), 76-78. 4. Cranford, R.E. and Roberts, J.C. 1986. Ethics committees: one of us is as smart as all of us. Michigan Hospitals 22(12), 14-16,31-34. 5. Cross, A.W. 1986. Pediatric ethics committees: learning from our experience. Journal of Pedianics 108(2), 242-243. 6. Robertson, J.D. 1984. Ethics committees in hospitals: alternative structures and responsibilities. Quality Review Bulletin 10,6-10. 7. Thomasma, D.C. 1985. Hospital ethics committees and hospital policy. Quality Review Bulletin 11(6), 204-209. 8. Fost, N. and Cranford,R.E. 1985. Hospital ethics committees: administrative aspects. Journal ofthe American Medical Association 253( 18), 2687-2692. 9. Linfors, E.W. 1988. How should hospital ethics committees function?Who should be included? North Carolina Medical Journal 49(3), 157-162. 10. Cranford, R.E. and Van Allen, E.J. 1985. The implications
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and applications of institutionalethics committees. American College of Surgeons Bulletin 70(6), 19-24. 11. Furlong, R.M. 1986.The social worker’s role on the institutional ethics committee. Social Work in Health Care 11(4), 93-100. 12. Fleetwood, J.E., Arnold, R.M. and Baron, R.J. 1989. Giving answers or raising questions? The problematic role of institutional ethics committees.Journal of Medical Ethics 15,137-142. 13. Van Allen, E.A. and Miles, S.H. 1987. Ethics committees in Minnesota hospitals. Minnesota Medicine 70(2), 77-80. 14. Green, W. 1989. The Philadelphia story. Hastings Centre Report 19(5), 26. 15. Brown, B.A., Miles, S.H. and Avoskar, M.A. 1987. The prevalence and design of ethics committees in nursing homes. Journal of the American Geriatric Society 35(1l), 1028-1033. 16. Avard, D., Griener, G. and Langstaff,J. 1985. Hospital ethics committees: survey reveals characteristics. Dimensions 62(2), 24-26. 17. Canadian Council on Hospital Accreditation. 1986. Guide to Accreditation of Canadian Health Care Facilities, CCHA, Ottawa. 18. Canadian Hospital Association. 1986.Institutional Ethics Committees: Recommendationsfor Action, CHA, Ottawa. 19. La Puma, J., Stocking,C.B., Silverstein,M.D. et al. 1988. An ethics consultation service in a teaching hospital. Journal of the American Medical Association 260(6), 808-811. 20. Cohen, C.B. 1990. The adolescence of ethics committees. Hastings Center Report 20(2), 19. This research was supported by a grant from National Health Research Development Program (NHRDP), Ottawa.
Appendix Considerationsin Establishingan Ethics Committee Some authors have suggested approaches to establishing ethics committees.They are summarized below, and include selected references.
1. Three or four interested staff members (nurses, physicians or other health professionals) form a committee and seek other interested members who are good listeners, or a hospital board selects some key staff members to “lead” in the formation of a committee. 2. Engage in committee self-education (e.g., reading, discussion, outside speakers) to become better acquainted with ethics in general, and the function of ethics committees in particular. 3. Determine the mission of the committee and gradually formulate guidelines, while remaining oriented to the process of developing the committee. 4. Work to enhance multidisciplinaryinvolvement, allowing members to get to know one another and to appreciate each other’s perspectives. 5. Proceed slowly, expecting some resistance. The committee should seek to earn acceptance. 6. Determine the authority your committee will have, and develop a framework for education and consultation. Cranford, R.E. and Roberts, J.C. 1986. Ethics Committees: none of us is as smart as all of us. Michigan Hospitals 22(12), 14-16,31-34. Linfors, E.W. ( 4 ) . 1988. Hospital ethics committees.North Carolina Medical Journal 49(3), 157-159. Niemira, Denise A. 1988. Grassroots grappling: ethics committees in rural hospitals. Annals ofhternal Medicine Dec. 15,981-983. Rues, L.A. 1987. Starting an institutionalethics committee: one physician’s experience,Healthcare Executive 2(4): 34-38. Weeks, L.C. 1987. Ethics committees.Journal of Nursing Administration 17(10),31-32. Janet L. Storch, RN,MHSA, PhD, is Professor and Dean, Faculty of Nursing, UniversiG of Calgary. Glenn G . Griener, BS, MA, PhD, is Assistant Professor, Medicine. Philosophy and Nursing, University of Alberta. Deborah A. Marshall, BSc, MHSA, is Administrative Fellow, University Hospital, Vancouver. Beverly A. Olineck, BComm, MHSA, is Administrative Fellow, St. Paul’s Hospital (GreyNuns), Saskatoon.
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